Tomoko Shima Hair Salon
Consultation form

Name:
Phone number:
Email Address:


1.Have you ever had any reactions to chemical or cosmetic procedures? (please answer Yes/No)


If yes, Please Explain:



2.Please list any skin, scalp or all ergicconditions:



3.Please list any medication you are currently taking:



4.Please list all previous (up to 3yr history) or current chemical processes:

	Permanent Wave
		Date of service:
		At home or professional:

	Single Process Color
		Date of service:
		At home or professional:	

	Highlights
		Date of service:
		At home or professional:

	Straighteners or Relaxers
		Date of service:
		At home or professional:



5.Are there any other special needs or considerations you would like the stylist to know about?